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C D

Fig. 9.3 Lateral radiograph (A) metallic marker and (B) diagram demonstrate a carpal boss at the base

the third metacarpal and capitate. Frontal radiograph (C) metallic marker and (D) diagram demonstrate

carpal boss and a theoretic depiction of associated displacement of the extensor carpi radialis brevis

the tendon.

C, Capitate; ECRB, extensor carpi radialis brevis; ECRL, extensor carpi radialis longus; M2, sec-

metacarpal; M3, third metacarpal; T, trapezoid. (From Porrino J, Maloney E, Chew FS. Current con-

ond cepts

of the carpal boss: pathophysiology, symptoms, clinical or imaging diagnosis, and management.

Prob Diag Radiol. 2015;44(5):462468 [Fig. 1]. ISSN 0363-0188,

Curr

diol.2015.02.008

http://www.sciencedirect.com/science/article/pii/S0363018815000274.)

https://doi.org/10.1067/j.cpra

138 9—A 48-YEAR-OLD MALE WITH A PAINFUL BUMP ON THE BACK OF HIS WRIST

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B C

Fig. 9.4 Radiographic manifestations of os styloideum. A lateral radiograph of the hand (A) demonstrates the osteophytic appearance of the extra ossification center (arrow). Clinically, a painless soft tissue lump is often evident. In another patient, a similar outgrowth (arrows) is evident on lateral (B) and frontal (C) radiographs. (From Resnick D. Diagnosis of Bone and Joint Disorders. 4th ed. Philadelphia: Saunders; 2002:1312.)

from carpal boss syndrome. Carpal boss syndrome has a slight male predominance and a peak incidence in the middle of the third decade of life. Trauma is often the common denominator in the development of carpal boss syndrome.

SIGNS AND SYMPTOMS

On physical examination, the carpal boss appears as a bony protuberance that can be seen more easily by having the patient flex the wrist (Fig. 9.5). The pain associated with this action can be reproduced by applying pressure to the soft tissue overlying the carpal boss. Patients with carpal boss syndrome demonstrate a positive hunchback sign; that is, the examiner can appreciate a bony prominence when palpating the carpal boss (see inflamed bursa may overlie the bony excrudescence and may confuse the diagnosis as the normal hard consistency of the carpal boss may be masked by the

Fig. 9.2). Occasionally an

1399—A 48-YEAR-OLD MALE WITH A PAINFUL BUMP ON THE BACK OF HIS WRIST

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Fig. 9.5 With wrist flexion, the prominence of the carpal boss becomes strikingly evident (arrow). (From Park MJ, Namdari S, Weiss A-P. The carpal boss: review of diagnosis and treatment. J Hand Surg. 2008;33(3):446449 [Fig. 2]. ISSN 0363-5023, https://doi.org/10.1016/j.jhsa.2007.11.029,

http://www.sciencedirect.com/science/article/pii/S0363502307011069.)

softer bursa. With acute trauma to the dorsum of the hand, ecchymosis over the carpal boss of the affected joint(s) may be present. Unlike the ganglion cysts of the wrist, which will transilluminate, the bony exostosis of the carpal boss will not transilluminate.

TESTING

Plain radiographs are indicated in all patients who present with a carpal boss to rule out fractures and to identify exostoses responsible for the symptoms (see

Figs. 9.3 and 9.4). Based on the patient’s clinical presentation, additional testing

may be warranted to exclude inflammatory arthritis, including a complete blood count, erythrocyte sedimentation rate, uric acid level, and antinuclear antibody testing. Magnetic resonance imaging (MRI), computerized tomography (CT), and ultrasound imaging of the fingers and wrist are indicated if joint instability, occult mass, occult fracture, infection, or tumor is suspected, as well as to further assess the condition of the overlying tendons ( bone scanning may be useful to identify stress fractures (Fig. 9.8).

Figs. 9.6 and 9.7). Radionuclide

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Fig. 9.6 A 36-year-old man with an asymptomatic palpable mass at the dorsal surface of his right wrist. Transverse (A) and longitudinal (B) ultrasound images obtained using a 12.5-MHz linear transducer on a Philips iu22 machine demonstrate a fragmented carpal boss at the dorsal base of the third metacarpal (arrowheads), adjacent to the trapezoid (T) and capitate (C). A radiograph from the same patient obtained with partial supination and ulnar deviation (C) improves conspicuity of the carpal boss (arrowheads) relative to the routine lateral view (D). (From Porrino J, Maloney E, Chew FS. Current concepts of the carpal boss: pathophysiology, symptoms, clinical or imaging diagnosis, and management. Curr Prob Diag Radiol. 2015;44(5):462468 [Fig. 4]. ISSN 0363-0188,

diol.2015.02.008

, http://www.sciencedirect.com/science/article/pii/S0363018815000274.)

https://doi.org/10.1067/j.cpra

DIFFERENTIAL DIAGNOSIS

The tentative diagnosis of carpal boss syndrome is made on clinical grounds and is confirmed by radiographic testing. Arthritis, tenosynovitis, or gout of the affected wrist may accompany carpal boss syndrome and exacerbate the patient’s pain. Dorsal ganglion cysts may mimic the presentation of carpal boss. Occasionally an inflamed bursa may overlie the bony excrudescence and may confuse the diagnosis, as the normal hard consistency of the carpal boss may be masked by the softer bursa ( clinical presentation. Other pathologic processes that may mimic the clinical presentation of carpal boss include fibromas, osteomas, exuberant synovium, fracture callus, and a variety of tumors (

Fig. 9.9). Occult fractures occasionally confuse the

Box 9.1).

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Fig. 9.7 A 28-year-old man with a palpable and painful mass at the dorsal surface of his left wrist. Lateral radiograph (A) demonstrates a carpal boss at the base of the third metacarpal (arrowhead). Sagittal (B) and coronal (C) computed tomography images demonstrate an osseous protuberance emerging from the base of the third metacarpal and extending over the dorsal surface of the capitate and trapezoid, consistent with a carpal boss (arrowheads). A three-dimensional reconstruction (D) demonstrates the carpal boss at the base of the third metacarpal, overlying the quadrangular trapezoid-capitate-metacarpal joint. M2, Second metacarpal; M3, third metacarpal. (From Porrino J, Maloney E, Chew FS. Current concepts of the carpal boss: pathophysiology, symptoms, clinical or imaging diagnosis, and management. Curr Prob Diag Radiol. 2015;44(5):462468 [Fig. 5]. ISSN 0363-0188,

article/pii/S0363018815000274

https://doi.org/10.1067/j.cpradiol.2015.02.008, http://www.sciencedirect.com/science/

142 9—A 48-YEAR-OLD MALE WITH A PAINFUL BUMP ON THE BACK OF HIS WRIST

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Fig. 9.8 A 39-year-old woman with dorsal wrist pain. Bone scan (A), acquired 3 hours after injection of 32mCi Tc-99m methyl diphosphonate, demonstrates increased radiotracer uptake in the left wrist (asterisk) compared with the right. Sagittal noncontrast computed tomography (B) and noncontrast proton-density fat-saturated magnetic resonance (MR) (C) images demonstrate a carpal boss at the base of the third metacarpal (arrowhead). Noncontrast axial T2 fat-saturated MR image (D) just proximal to the carpal boss demonstrates abnormal fluid in the tendon sheath of the extensor carpi radialis brevis (arrowhead), consistent with tenosynovitis. (From Porrino J, Maloney E, Chew FS. Current concepts of the carpal boss: pathophysiology, symptoms, clinical or imaging diagnosis, and management. Curr Prob Diag Radiol. 2015;44(5):462468 [Fig. 2]. ISSN 0363-0188,

2015.02.008

, http://www.sciencedirect.com/science/article/pii/S0363018815000274.)

https://doi.org/10.1067/j.cpradiol.

1439—A 48-YEAR-OLD MALE WITH A PAINFUL BUMP ON THE BACK OF HIS WRIST

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Fig. 9.9 Occasionally an inflamed bursa may overlie the bony excrudescence and may confuse the diagnosis, as the normal hard consistency of the carpal boss may be masked by the softer bursa. (From Park MJ, Namdari S, Weiss A-P. The carpal boss: review of diagnosis and treatment. J Hand Surg. 2008;33(3):446449 [Fig. 4]. ISSN 0363-5023, https://doi.org/10.1016/j.jhsa.2007.11.029,

http://www.sciencedirect.com/science/article/pii/S0363502307011069.)

BOX 9.1 ’ Differential Diagnosis of Carpal Boss

’

Ganglion cyst

’

Inflamed bursa

’

Synovitis

’

Fracture callus

’

Exuberant synovium

’

Fibroma

’

Giant cell tumor

’

Aneurysmal bone cyst

’

Unicameral bone cyst

’

Lipoma

’

Neural tumors

’

Interosseous ganglions

’

Osteoid osteoma

’

Osteochondroma

’

Osteosarcoma

’

Metastatic disease

144 9—A 48-YEAR-OLD MALE WITH A PAINFUL BUMP ON THE BACK OF HIS WRIST

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Inflamed tendon and joint

Fig. 9.10 Injection technique for carpal boss, or os styloideum. (From Waldman SD. Carpal boss. In:

Atlas of Pain Management Injection Techniques. 2nd ed. Philadelphia: Saunders; 2007:268.)

Carpal boss

Trapezoid

Extenso

indicis

TREATMENT

Initial treatment of the pain and functional disability associated with a carpal boss consists of nonsteroidal antiinflammatory drugs, simple analgesics, or cyclooxygenase-2 inhibitors. Physical modalities, including local heat and gentle range-of-motion exercises, should be introduced to avoid loss of function. Vigorous exercises should be avoided because they will exacerbate the patient’s symptoms. A nighttime splint to protect the fingers may be helpful. If sleep disturbance is present, low-dose tricyclic antidepressants are indicated. If the patient does not respond to these conservative modalities, a trial of injection therapy with local anesthetic and steroid is a reasonable next step ( exploration and removal of the carpal boss are requiredfor symptomatic relief.

Fig. 9.10). Rarely, surgical

HIGH-YIELD TAKEAWAYS

• The patient is afebrile, making an acute infectious etiology unlikely.

• The patient’s symptomatology is most likely due to trauma to the wrist from a

fall from a ladder.

• Physical examination and testing should be focused on the identification of the

other pathologic processes that may mimic the clinical diagnosis of carpa l boss.

• The patient exhibits the physical examination findings that are highly suggestive

of carpal boss.

• The patient’s symptoms are localized.

• Plain radiographs of the wrist will help identify bony abnormalities of the wrist,

including fractures, dislocations, and osseous tumors.

• Ultrasound imaging, CT scanning, and MRI of the wrist and pelvis may help

identify less common causes of wrist pain.

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